Current techniques in postmortem imaging with specific attention to paediatric applications

In this review we discuss the decline of and current controversies regarding conventional autopsies and the use of postmortem radiology as an adjunct to and a possible alternative for the conventional autopsy. We will address the radiological techniques and applications for postmortem imaging in childre

Preface

AimThis was a one-year follow-up of families referred to support services after the parents visited the emergency department due to intimate partner violence, substance abuse or a suicide attempt. Its aim was to evaluate the well-being of any children. MethodsData on families identified a year earlier by the Amsterdam protocol were gathered from child protective services and parent and child self-reports in two Dutch regions from 2012-2015. ResultsWe included 399 children (52%) boys with a median age of eight years (range 1-18) in the study using child protective services data. Of the 101 families who participated in the first measurement, 67 responded one year after the parent's emergency department visit. The results showed that 20% of the children had no or minor problems, voluntary support services were involved in 60% of cases and child protective services were involved in 20%. Compared to their first assessment a year earlier, the children's psychosocial problems had not increased, but this could have been an underestimation due to selective responses. ConclusionThe Amsterdam protocol was valuable in referring families to voluntary support services, but given the ongoing problems in some families, professionals need to carefully monitor whether support services are sufficiently effectiv

Educational paper: Abusive Head Trauma Part I. Clinical aspects

Abusive Head Trauma (AHT) refers to the combination of findings formerly described as shaken baby syndrome. Although these findings can be caused by shaking, it has become clear that in many cases there may have been impact trauma as well. Therefore a less specific term has been adopted by the American Academy of Pediatrics. AHT is a relatively common cause of childhood neurotrauma with an estimated incidence of 14–40 cases per 100,000 children under the age of 1 year. About 15–23% of these children die within hours or days after the incident. Studies among AHT survivors demonstrate that approximately one-third of the children are severely disabled, one-third of them are moderately disabled and one-third have no or only mild symptoms. Other publications suggest that neurological problems can occur after a symptom-free interval and that half of these children have IQs below the 10th percentile. Clinical findings are depending on the definitions used, but AHT should be considered in all children with neurological signs and symptoms especially if no or only mild trauma is described. Subdural haematomas are the most reported finding. The only feature that has been identified discriminating AHT from accidental injury is apnoea. Conclusion: AHT should be approached with a structured approach, as in any other (potentially lethal) disease. The clinician can only establish this diagnosis if he/she has knowledge of the signs and symptoms of AHT, risk factors, the differential diagnosis and which additional investigations to perform, the more so since parents seldom will describe the true state of affairs spontaneously

Een meisje van 1 jaar met perineumletsel

A one year old girl was presented at the ER because of a large perineal impalement injury. She required surgery and a stoma was placed. Initially no causative mechanism for the injury was described. Further history-taking revealed she had jumped in the bath on a castle-shaped shampoo bottle. This explanation matches both the injury and the developmental stage of the child. With this case we aim to underline the importance of detailed history-taking in order to distinguish between accident and abuse. The history-taking should include a detailed history of the mechanism of trauma, in order to relate this to the injury and the developmental stage of the child. If there is a suspicion of child abuse risk factors for child abuse should be sorted out. If there is doubt about the relation between the mechanism described and the injury, a forensic expert should be consulted

Postmortem CT compared to autopsy in children; concordance in a forensic setting

The aim of this study is to assess the accuracy of postmortem CT (PMCT) in determining the cause of death in children who underwent a forensic autopsy because of a suspected nonnatural death. We selected forensic pediatric autopsies at the Netherlands Forensic Institute, whereby the subject underwent PMCT between 1-1-2008 and 31-12-2012. Cause of death was independently scored by a radiologist and a pathologist. Cause of death was classified (1) in categories being natural, unnatural, and unknown; (2) according to the ICD-10; and (3) according to institutional classification. In the study period, 189 pediatric forensic autopsies were performed. Fifteen were excluded because of putrefaction. Of the remaining 174 autopsies, 98 (56 %) underwent PMCT. PMCT and autopsy identified the same category in 69/98 cases (70 %, kappa 0.49). They identified the same cause of death in 66/98 cases (67 %, kappa 0.5) using ICD-10; in 71/98 (72 %, kappa 0.62) using a forensic classification. PMCT performed better in unnatural deaths (59-67 % agreement) than in natural deaths (0 % agreement). If no cause of death was detected with autopsy, PMCT failed to identify a cause of death in 98 % (39/40). Pediatric PMCT does identify the majority of unnatural causes of death, but does not identify new diagnoses (true positives) if no cause of death is found during autopsy. Diagnostic accuracy in natural deaths is low. aEuro cent The case mix is an important predictor for the concordance between PMCT and autopsy. aEuro cent In case of an unnatural death, 72--81 % of PMCT results matches autopsy results. aEuro cent In case of a natural death, 0 % of PMCT results matches autopsy results. aEuro cent If no cause of death is identified with autopsy, 98 % of PMCT results concur

Age determination of subdural hematomas with CT and MRI: a systematic review

To systematically review the literature on dating subdural hematomas (SDHs) on CT and MRI scans. We performed a systematic review in MEDLINE, EMBASE and Cochrane to search for articles that described the appearance of SDHs on CT or MRI in relation to time between trauma and scanning. Two researchers independently screened the articles, assessed methodological quality and performed data extraction. Medians with interquartile ranges were calculated. Differences were tested with a Mann-Whitney U or Kruskal-Wallis H test. We included 22 studies describing 973 SDHs on CT and 4 studies describing 83 SDHs on MRI. Data from 17 studies (413 SDHs) could be pooled. There were significant differences between time intervals for the different densities on CT (p <0.001). Time interval differed significantly between children and adults for iso- and hypodensity (p=0.000) and hyperdensity (p=0.046). Time interval did not differ significantly between abused and non-abused children. On MRI, time intervals for different signal intensities on T1 and T2 did not differ significantly (p=0.108 and p=0.194, respectively). Most time intervals of the different appearances of SDHs on CT and MRI are broad and overlapping. Therefore CT or MRI findings cannot be used to accurately date SDH

Pneumomediastinum and soft tissue emphysema in pediatric hanging

Postmortem computed tomography (CT) is increasingly being used as a tool in forensic pathology. The exact value of postmortem imaging in detecting specific conditions has not yet been established, but in specific cases, it can be used as a diagnostic tool demonstrating findings that remain undetected during autopsy, as in this case. Pneumomediastinum and soft tissue emphysema were detected with postmortem CT in a 3-year-old girl after hanging. It was not found during autopsy. This radiological finding matches 3 adult cases previously described. It is assumed that in this case, the first reported in a child, hanging was the most likely cause as well. In the adult cases, it was interpreted as a vital sign; the person must have been alive to create a pressure gradient causing rupture of the alveoli. This case demonstrates one of the added values of postmortem imaging, the possibility of demonstrating findings that remain undetected during autops